Documentation Training
Staff Training Hub
Role-specific documentation guidance built from your audit findings. Every tip shows exactly what to write so revenue is captured automatically — every time.
Quick Reference — Top 8 Documentation Rules
Post this at the nurses station. These 8 rules capture the most missed revenue across SNF/ALF/CAH facilities.
🩺 Nursing Must Document
1. Incontinence: "Urinary incontinence present — incontinent care provided each shift per care plan"
2. Skin: "Pressure injury Stage [X] located at [site] — wound care per orders [frequency]"
3. Falls: "Fall risk HIGH per Morse scale score [X] — bed alarm in use, non-skid footwear applied"
4. Pain: "Patient reports [X/10] pain at [location] — consistent with [diagnosis per MD]"
👨⚕️ Physician Must Document
1. Dementia: "Alzheimer's dementia, Stage [X] per GDS — [mild/moderate/severe] cognitive impairment"
2. CHF: "Chronic systolic heart failure, EF [X]% — [compensated/decompensated]"
3. Depression: "Major depressive disorder — PHQ-9 score [X] — started [medication] [dose]"
4. Dysphagia: "Dysphagia present — speech therapy consulted — [diet texture] ordered"
🦽 Therapy Must Document
1. FIM scores: List ALL 18 FIM items — locomotion, transfers, self-care — each with a score
2. Skilled need: "Continued skilled PT/OT needed for [specific goal] — without skilled intervention [consequence]"
3. Cognitive: "Cognitive deficits affect therapy participation — patient requires [level] cueing"
4. Dysphagia: "SLP evaluation completed — dysphagia [severity] — [diet/thickened liquids] ordered"
📊 MDS Coordinator Must Do
1. Section I: Code EVERY active diagnosis — not just the admitting dx
2. Section J: Code falls, pain, pressure ulcers, dysphagia from nursing notes
3. Section N: Count ALL medication classes — anticoagulants, antipsychotics, antibiotics
4. ARD: Set ARD to maximize therapy days in the look-back window for PDPM
Documentation Training Tips
Each tip shows what was written vs. what should be written — with the direct revenue impact explained.
Most Missed ICD-10 Codes — SNF/ALF Reference
These codes are consistently undercoded across facilities. Every one of them requires specific documentation language to support billing.